6. The Crackling

        It was Monday again. Not that it really made a difference since I had spent a good part of my weekend at Brooklyn Hospital. I was still shaken about Weiss’ case, but I had decided to just work it off.

         I took the new chart of the day and read it before going into the room. Amy Green, 25 years old, came in with intense chest pain. Her initial workup was clean, but the chest x-ray showed an important pleural effusion. The fluid was drained with thoracostomy which showed a cloudy material that was now in the lab. Weird. She was in pain medication, but from what I could see through the door she was still in bad shape.
‘Good morning, Ms. Green. I am Lisa Diaz and I’ll be your doctor from now on. How are you?

‘Morning, doctor. My chest is still hurting.’

‘I see, let’s get to that. When did the pain start?’

Amy was a nice girl, a little shy but very smart. She was in Law school and was anxious to relieve her pain and go home. She told me the chest pain had started that morning very suddenly. She thought she was having a heart attack so she came to the hospital immediately. She also began having a hard time breathing, but that improved after the thoracostomy. The medications she was receiving helped the pain but only a little. Swallowing made the pain worse, and sometimes she coughed, but apart from that, she denied other symptoms, medical conditions, or drug use.

I went on to the physical exam. While I was auscultating her chest something seemed odd, it was like a crepitation but exactly above her heart. It reminded me of a friction rub, but it wasn’t, it was different. Could it be air? Like a pneumomediastinum? I wondered. But what in the world could cause that in this girl… Well, I was going to need a CAT scan of her chest. I let Amy know that and said I would be back later. I needed to find Dr. Collins.

I found her in the ward talking to one of Peter’s patients, Mr. Castle. She loved talking to the patients she cared for, and the patients loved her, it was a beautiful scene to watch. After saying goodbye to Mr. Castle she saw me waiting and smiled.

‘How are you today, Dr. Diaz?’

‘I am fine, Dr. Collins, thank you.’ I smiled back. ‘Can I borrow you for a second?’

I quickly presented Amy’s case to her and said I would like to order a CAT scan of her chest and then we could discuss it in our 11 AM meeting. She seemed puzzled by Amy’s case and agreed to the CAT scan.

‘Which bed is she in? I am going to stop by and meet her before rounds.’

Just before 11 AM I got the imaging results and found Collins and Peter waiting for me. 

‘There you are!’ She welcomed me. ‘Let’s start with Amy. I already filled Peter in. You were right, she does not look well. Do you have her CAT scan?’

‘Yes! Right here.’

The images showed what seemed like a collapsed left lung with a collection of heterogeneous material. Peter also pointed out that there was in fact some air in the mediastinum.

‘That could explain her Hamman sign, the crackling sound in her heart exam.’ Lucy said, ‘But I don’t think she has spontaneous pneumomediastinum. Her presentation would be more benign, and it doesn’t account for her lung findings. Do you agree?’

We both nodded.

‘What else then? Let’s brainstorm this.’

‘A malignancy?’ I tried.

‘It has to be on our list, but I think it’s unlikely. Her case seems so sudden.’

‘A perforation?’ Peter said.

‘Hum.. that’s a good start. That air has to come from somewhere. Where?’

‘In the chest, is either lungs or GI tract.’ I hypothesized. ‘Esophageal perforation? She did say the pain was worse when she swallowed.’

‘Boerhaave Syndrome. I like it.’ She grinned. ‘Let’s order a contrast esophagram now, Lisa. And find someone on surgery to let them know about the case. You may be right and she could need surgery asap.’

I checked Amy’s contrast esophagram, and there it was. An obvious contrast leak indicating perforation in the wall of her esophagus. She was taken to surgery to correct the problem and I went back to the ward to finish a few things for my other patients. I had promised Jax we would lunch together in the cafeteria at 1 PM so I had, well, 10 minutes. I typed one-half of a discharge summary and gave up.

‘Are my eyes tricking me? Is that really you, Diaz?’ Jax said with his hand in his chest. ‘I was waiting for your typical cancel text.’ He laughed.

‘Shut up.’ I smiled. We had barely seen each other lately. Even though we lived together, our interactions in the past week had been basically accidentally running into each other in the hospital. It wasn’t only my fault though, both of our schedules just didn’t match, not even on the weekends, so we promised to make time for lunch today.

‘How are you holding up, Liz?’

‘I’m okay Jax, really.’ I said more harshly than I had meant to. He had been worrying about me ever since Jake Weiss’ case.

        'You need to talk about this.'

        'There's nothing to talk about.'

‘Fine, Jeez…’ He sighed and stole one of my Cheetos. ‘Forget I asked. How is your day going?’

I went on to tell him about Amy’s case, how Collins helped me with the clinical reasoning so I could think of her diagnosis and all that. Jax is the best listener I know, he asks questions and vibrates with the narrative of any story you share with him.

‘I’m happy for you, Lisa. Didn’t expect anything less.’ He said after I was done.

‘Thanks, Jax.’ I smiled.

‘And why the hell did this girl have Boerhaave Syndrome?’

‘I know, right? She’s not an alcoholic that vomits all the time.’

‘So she wasn’t vomiting?’ He asked.

‘No. She denied any other symptoms.’

He stopped for a moment. ‘Well, unless she was making herself vomit…’ He chewed his sandwich. ‘I don’t think she would consider that a symptom.’

I thought for a bit. Maybe she could fit the bulimic pattern.

‘Unbelievable. How do you get people so easily?’ I said madly as I got up from the table and headed to the ICU. Jax laughed.

‘It's why you love me, Liz.’

       I was already planning on checking on Amy after her surgery, but Jax’s suspicion made me expedite my plans. Amy seemed better, I sat down beside her and we talked about her life. And, damn, he was right. A few minutes into the conversation and she told me in tears about her episodes of binge eating and self-provoked vomiting. Her problem was so much deeper than I’d thought. I stayed with her for a while, wondering how I could help this girl. In the end, she agreed to see a psychiatrist and I told her I would stop by the next day so we could chat a bit more.  

        ‘I’ll wait for you. Thank you, Dr. Diaz.’

        I got home and found a pineapple pizza - aka the best pizza ever made - waiting for me at the table. Something was up.

       ‘I know you are not ready yet.’ Jax started when he saw me getting into the kitchen. ‘But when you are, you can talk to me about it, you know?’

        I smiled. ‘I know. Thanks, Jax.’


        ‘And by the way, you were right. She was bulimic.’

        ‘Again, anytime.’ He smirked.

        ‘Jerk.’ I said and he started laughing.


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